London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1900

[Report of the Medical Officer of Health for London County Council]

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The nervous system—From the onset of plague the mental faculties are affected. The paindrawn,
haggard expression of countenance would seem to indicate that the patient is suffering from pain
probably arising from the glandular swellings. This speedily gives way to, or may be wholly supplanted
by, a peculiar listlessness and apathy of feature well-nigh characteristic of the disease.
Delirium may, on the other hand, usher in the disease, accompanied by what would appear to be a
suicidal tendency, inasmuch as the patient may rush to the verandah or window, to the staircase, or
out into the street. The outburst is, however, unattended with any fixed idea or purpose. If gently
restrained the patient is soon turned from his apparent purpose, and his aimless intention may assume
the form of wandering in the street or taking passage by train to an uncertain destination. It would
appear by the answers to questions that the patient is sensible, but his statements are frequently
untrue, the memory being at fault. Deafness, thickness of speech, laryngeal paralysis, muscular
tremor, loss of co-ordination in almost any group of muscles are common features in the disease.
Sleeplessness is a distressing symptom, and of so constant an occurrence as to constitute one
of the most trying conditions to deal with. In fatal cases, picking at the bed clothes, busy delirium
and coma prevail, and usually herald death.
The cutaneous system—Petechiæ occasionally appear, especially in fatal cases, over the seat of
the bubo or on the limb affected by the bubo, or still more rarely on other parts of the body or limbs.
Subcutaneous haemorrhage of an extensive character may occur around a bubo, or smaller
hæmorrhages may develope elsewhere. Small patches of skin may slough, buboes suppurate, leaving
foul, deep, ulcerated surfaces with ragged edges. Boils and so called carbuncles are exceptional, and
a distinctive rash is very uncommon ; when a rash occurs it closely resembles the rash of typhus.
The lymphatic system,—The toxic agency in plague seems to expend its virulence largely on
the glands. Although a bubo may be apparent in only one region of the body, post mortem examination
reveals the fact that almost every gland in the body is swollen. Buboes occur most frequently
in the groin, and the order of frequency with which buboes appear in the groin, axilla, and neck, stand
as 50, 30, and 15, in every hundred cases which show buboes. The bubo may appear at the onset and
may be present even with the initial rigor; more usually, however, it does not develope until the
second day, when it will be found as a large, smooth, bun-shaped swelling. On palpation it feels
resilient and rather elastic and resistant. The bubo may disappear, but suppuration is the rule at the
seventh to the ninth day of the illness. The glands in the neighbourhood of the bubo are obscured
and incorporated in the swelling. (Edema may extend over a wide area around the bubo, and a subcutaneous
haemorrhage may in the case of the groin buboes extend down the thigh, backwards to the
gluteal region, and upwards on the abdominal wall. When the axillary glands are involved the
swelling and oedema may extend over the chest, down the side to the ilium, and backwards to the
scapular region. In the neck the effusion is at times sufficient to press upon the trachea and larynx.
The pain caused by the adenitis and bubo may be so great as to be excruciating, and causes
the affected limb to be placed in a position calculated to best relieve tension; the lower limb is
flexed on the abdomen ; the upper limb placed away from the trunk, the patient lying on the back, or
inclined towards, or altogether turned on, the affected side.
Septiccemic plague.
Although the term "bubonic " is usually associated with what is called true plague, it is now
known that glands may enlarge and toxic symptoms develope without the formation of a bubo. The
dose of poison seems so large that a general infection of the blood ensues and the patient is struck
down suddenly without much chance of recovery. There is but little reaction after the onset; the
pulse fails from the first; the temperature rises suddenly, it may be to a hyperpyrexic height; the
prostration is extreme; delirium or coma may suddenly set in and continue to the end. The glands
never attain a large size, although every gland in the body may be swollen. Deep and firm pressure
may elicit pain over the groin, iliac, axillary, or cervical group of glands, but usually this is obscured
by the mental condition of the patient. The septicaamic type is a very fatal variety of plague.
Pneumonic plague.
During the epidemic of plague in Bombay in 1896 attention was drawn by Childe to the
abnormal number of deaths returned as ' pneumonia'. A bacteriological investigation of such cases
showed that the plague bacillus was present in the sputum in almost a pure culture, and since that
time the pneumonic variety of plague has been recognised as a distinct and very fatal form of the
disease. The symptoms are—expectoration of a quantity of watery sputum, frequently tinged with
blood, and occasionally some frothy mucus; hurried or laboured breathing, cardiac discomfort, restlessness,
sleeplessness and early delirium. The local signs are patchy, irregular, pneumonic consolidation
of the lungs, congestion of the bases, and intermittent evidences of bronchial catarrh. Buboes do
not occur, nor are the glands found swollen either during life or after death.
Duration of the disease.
The most fatal period in bubonic plague is from the fifth to the seventh day, but death
may take place earlier or later. Suppuration of the bubo and bursting of the abscess occurs
usually between the eighth and twelfth day, and should the patient survive until that period the

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